 TRUE
STORY. To Nancy Weiss, things looked bad: "Something had to be done, and
fast, or my daughter would be dead." The teenager was potentially suicidal
and getting into drugs, and had been to a dozen therapists in Maryland, where
the two lived. Weiss (whose name has been changed to preserve her privacy)
is a single mom and education consultant. She had health insurance and a therapist's
strong recommendation that her daughter get away--friends were linked to many
of her problems--and be treated at a specialized residential facility in Utah. "So
I called my insurance company, and they said no dice: They would only pay for
something local. And staying local was part of the whole problem!" Weiss
dipped into her daughter's college fund--"if she was dead, there wouldn't
be any college"--and began paying $6,120 a month for out-of-state treatment.
WHAT'S UP. Health insurance companies frequently refuse to pay for you to
see the doctor you want to see. "It happens every day. This is huge," says
Mary Jane Stull, a former claims processor who counsels patients on ways to
fight back. (Her company's Web site is insurancenightmare.com.) A woman with
cancer in both breasts was told she could not see a specialist outside her
HMO even though the HMO surgeon had missed a tumor. A car accident victim was
told she didn't have coverage for the specialists and emergency personnel who
cared for her. And when companies say no, most patients give up. The Rand think
tank looked at denial-of-coverage decisions in two of the nation's largest
HMOs and found only 3 or 4 appeals per 1,000 members.
BATTLE PLAN. Yet the Rand study also found that 42 percent of appeals for
additional services are decided in favor of the patient. You can tilt the balance
further in your favor. Get past the insurer's customer service reps at the
1-800 phone lines. They aren't healthcare professionals. Most companies have "case
managers" who are nurses: Ask to be assigned to one, saying you have a
complicated illness that needs to be carefully managed. (If you run into resistance,
ask your current doctor or a nurse in the doctor's office to call the insurer
for you.) Write letters citing a serious threat to your health. The case manager
may be more understanding of your medical needs. If not, ask for a review by
the company's medical director. Your employer may also be willing to switch
you to a more flexible insurance option "for cause" (that's what
happened with the breast cancer patient). As for Weiss, she hired Stull. After
a bit of back and forth, the insurer decided the Utah treatment was covered--and
is reimbursing some past expenses as well.
BONUS TIP. Proper language helps your appeal. Patients
Are Powerful, a nonprofit
based in Penryn, Calif., has crafted strongly worded model letters requesting
payment for a specialist or second opinion. The letters use phrases like "imminent
and serious threat to my health" and insist on a decision within five
days. You can download and customize these letters at patientsarepowerful.org.
-Josh Fischman
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